Management Branch Office of Licensing

VERIFICATION OF EXPERIENCE This is to certify that___________________________________________________________________ (Applicant Name)

(Date of Birth)

was working in ________________________________ of ______________________________ (Type of Facility: Nursing Home/Hospital/Other-explain) (Facility Name) in the following capacity _______________________________________________________________ (Nursing Home Administrator/DON/Other-explain)

I have attached a job description for the above named individual. The above named practiced for ___________ hours per week, from _____________ to _____________ (mm/dd/yyyy)

(mm/dd/yyyy)

Place of Employment: Address ___________________________________________________________________________________ (Number and Street) ___________________________________________________________________________________ (City, State, Zip) I certify that all statements made on this form are true, complete and correct to the best of my knowledge and belief and are made in good faith. ________________________________________ Employer’s Signature

________________________________________ Type or print Name

________________________________________ Employer’s Title/Position

________________________________________ Date

Applicant: You must submit a separate Verification of Experience form for each place of employment and for each job title you wish to have considered.

1560 Broadway, Suite 1350, Denver, CO 80202 P 303.894.7800

F 303.894.7693 www.dora.colorado.gov/professions